PSYCHOSOCIAL ISSUES FOR

CHILDREN AND FAMILIES IN

DISASTERS:
A Guide For The Primary Care
Physician
Author:
Work Group on Disasters
American Academy of Pediatrics

American Academy of Pediatrics

141 Northwest Point Boulevard
PO Box 927
Elk Grove Village, IL 60009-0927

AMERICAN ACADEMY OF PEDIATRICS

The American Academy of Pediatrics was founded in June 1930 by 35 pediatricians

who met in Detroit in response to the need for an independent pediatric forum. At that
time, the idea that children have special developmental and health care needs was a
new one. Preventive health practices now associated with child care C such as
immunization and regular health examinations C were only just beginning to change
the custom of treating children as "miniature adults."

Today, the Academy unites 47,000 pediatricians throughout the Americas to ensure
for all young people the attainment of their full potential for physical, emotional, and
social health. To this end, the Academy dedicates its resources to professional
education, advocacy for children, representation of pediatricians, public education,
access to health care, and service to children.

More than 50 councils, committees, and task forces C addressing interests as diverse
as infectious and communicable diseases, injury and poison prevention, emergency
medicine, substance abuse, and school health C develop many of the Academy's
policies, programs, and publications. For more information on how to obtain these
materials, phone the Academy at 708/228-5005.

FOREWORD

The publication of this booklet marks not only a new and important collaboration
between the Federal Center For Mental Health Services and the American Academy
of Pediatrics, but a landmark initiative to enhance services to children and families
following disasters. The funding of the booklet's development by the Federal
Emergency Management Agency is dramatic evidence of not only the importance of
the topic but their commitment to comprehensive assistance to those impacted by
disasters.

In the organization of services in response to the psychological sequelae of major

disasters, the focus of interventions for children has been primarily the school system.
The practicing physician frequently has been an unrecognized, and largely unsolicited,
part of the psychological recovery mosaic.

This booklet represents an attempt to provide physicians with information to explore a

variety of roles in disaster response and recovery as well as tools to better assess and
treat the needs of their patients.

The aftermath of large scale disasters places strain on the entire fabric of a community
and its residents. The health care provider may often be both the victim/survivor and
the source of assistance. It is our hope that this booklet will provide a resource to help
physicians, their patients, and their communities cope more effectively in very
difficult times.

Joe M. Sanders, Jr, MD

Executive Director
American Academy of Pediatrics

Brian W. Flynn, EdD

Chief, Emergency Services and
Disaster Relief Branch
Center for Mental Health Services
Substance Abuse and Mental Health
Services Administration

Contents

Foreword

Acknowledgements

Introduction

Characteristics of Disasters

Impact of Disasters

Reactions of Children Adolescents to a Disaster

Specific Problems and Recommendations

General Recommendations

Outside the Office: Issues for Community Involvement

References

Appendix A: Potential Resources in a Disaster Environment

Appendix B: Pediatric Emotional Distress Scale

Introduction

In recent years, the news media has brought the realities of disasters in the United
States and the world to the attention of the public. Since the 1974 Disaster Relief Act
became law, there have been more than 800 major federally designated disasters in the
United States and more than 8000 deaths annually due to natural and human-caused
disasters.[17]

The legacy of a disaster is serious and has widespread physical and emotional
sequelae. The emotional impact of a disaster often persists well after the physical
impact. Children may evidence symptoms related to the disaster either at home or at
school. These are usually normal reactions to an abnormal situation; therefore, it is
important for the physician to know how to recognize the psychologic sequelae in
order to assist the child and family.

The focus of this manual is on how the child health care provider may better prepare,
assess, and treat youngsters and their families in the event of a disaster. As a
recognized leader in a community, the physician also may be called upon to address
community needs in case of such events. This manual also will aid the physician in
assuming this role.

CHARACTERISTICS OF DISASTERS

NATURAL VS HUMAN-CAUSED

A disaster is usually defined as an event that

1. involves destruction of property

2. includes injury and/or loss of life
3. affects a large population and is shared by many families.

Disasters are events that are out of the realm of the normal human experience and,
from a psychologic standpoint, are traumatic enough to induce stress in anyone,
regardless of previous experience or function.19 "Catastrophic disasters" are disasters
that may have an impact on tens of thousands of people and disrupt entire
communities.

Disasters are usually classified as natural or human-caused, and the differences

between them are outlined in Table 1.

TABLE 1. NATURAL VS HUMAN-CAUSED DISASTERS

Natural Human-Caused
Causes Forces of nature Human error, malfunctioning technology
Earthquakes, Airplane crashes, major chemical leaks,
Examples
hurricanes, floods nuclear reactor accidents
Blame No one Person, government, business
Locations may be inaccessible to rescuers,
Scope Various locations
unfamiliar to survivors, little advance warning
Postdisaster Higher, often felt by family members not
High
distress involved in actual disaster

Examples of human-caused disasters include mass transportation (air, rail, ship, or

car) accidents, fire, dissemination of environmental toxins, civil unrest, crime, and
terrorism. Natural disasters include such events as hurricanes, earthquakes, tornadoes,
and lightning strikes, and may be the source of community-wide destruction that is
"catastrophic" in scope. Sometimes disasters occur due to a combination of nature and
technology, such as an airplane crash secondary to poor weather conditions.

Since there is no one to blame in a natural disaster, the victims may direct their anger
inwardly and feel guilty for not taking the necessary precautions, or they may believe
that it was "God's will" or a punishment. In the absence of someone to blame, victims
may project their anger onto caretakers, including health care professionals.

Human-caused disasters are associated with higher levels of posttraumatic distress

than natural disasters.[30] For example, in mass transport disasters, fatalities are
sometimes universal, and mutilation and serious injuries often occur. Some survivors
develop a phobia for that type of transportation. In human-caused disasters, victims
may feel anger toward and blame an individual or group of people whom they hold
responsible for the event.

War is another traumatic stressor for children and families which may lead a child to
experience the death of a loved one, loss of home and possessions, and relocation.
During war, children often witness violence. Many war-related problems and feelings
that children and adolescents must overcome during a war are similar to those faced in
the aftermath of natural and human-caused disasters.[28]

This manual is meant to assist primary care physicians in responding to the most
common types of natural and human-caused disasters. Other types of trauma may also
have a similar impact on children and families, but are beyond the scope of this
manual. For example, victims of child abuse and children who experience a vehicular
accident may present similar challenges.

NATURAL HISTORY OF DISASTERS

The phases of a disaster, whether human-caused or natural, have been studied by the
National Institute of Mental Health,15 which lists them as follows:

1. Predisaster conditions of the community, family, and individual.

2. Warning of impending disaster given by the media or weather changes.
3. Threat of disaster, immediately preceding the actual impact.
4. Immediately postdisaster, when survivors take inventory of events.
5. Rescue phase, in which survivors and emergency workers join to save those
affected by the disaster.
6. Remediation performed by the Red Cross, insurance adjusters, federal
government, and local relief efforts.
7. Recovery period, in which physical structures are rebuilt and families and
individuals begin to cope.

IMPACT OF DISASTERS

EFFECTS OF A DISASTER ON A COMMUNITY

Since children do not live in a vacuum, it is important to consider the effects of a

disaster on their surroundings and helpers C the community, the family, and the
primary care physician C and how those may reflect on the children. Each disaster
differs in its effects based on its scope, intensity, and the characteristics of the
predisaster community, family, and individual personalities.

The effects of a disaster on a community are often widespread, and include the
following:

• destruction of infrastructure
• absence of electricity, sanitation, and potable water
• destruction of physical contact with the outside world (eg, roadways, phones,
and bridges)
• dissipation of community cohesion due to death and injury
• vulnerability and exploitation due to disaster and media sensationalism[23]
• potential for recurrence

EFFECTS OF A DISASTER ON CHILDREN AND THEIR

FAMILIES
The possible effects of a disaster on the family are varied and extremely important to
the child. These include the following events:

• death or physical injury to a family member;

• loss of family dwelling or possessions;
• relocation (school changes);
• job loss; and
• parental disorganization or dysfunction

The primary care physician must consider the physical trauma to the child and family
prior to the emotional effects. However, it is important that the physician, as a trusted
person, gives the parent permission to take care of his/her own needs so that he/she
might better help the child to cope (analogous to the parent putting on the oxygen
mask first in an airplane emergency, and then putting on the child's mask). This may
include referring the parent for counseling.

The important caveat to remember is that, in most cases, the children and families are
having a normal reaction to an abnormal situation. It is often easier for parents to seek
treatment for their child before seeking treatment for themselves, but sometimes a
parent will present a symptomatic child as a way of presenting his or her own
symptoms.

Parental adjustment to the disaster is an important factor in the child's adjustment. If

there are any preexisting family conflicts or psychopathology, these may impede
adaptation to the life changes caused by a disaster. Domestic violence or parental
alcohol or substance abuse also may increase after a disaster and seriously impede the
family's recovery. If a parent relies too heavily on the child for support, or
alternatively, is overprotective, a child's personal resolution of the effects of a disaster
may be delayed.

A parent's reaction to the child's behavior is also important. Parental response to a

disaster correlates well with that of the child.[7,24] Parents may be so upset that they
may not be aware of their child's troubles.[4,24]

PREEXISTING RISK FACTORS

The preexisting life situation of the child or adolescent needs to be understood for a
better assessment of disaster effects. For example, there may be preexisting physical
handicaps or psychopathology in the child or family members. In dysfunctional
families, there may be an increased tendency to abuse alcohol or other drugs. Children
with developmental disabilities or physical handicaps may need added care due to
interruption of their care, loss of facilities (such as handicap access buildings), or
worsening of their condition secondary to the disaster. These children and families
should be targeted for outreach after the disaster, as well as predisaster planning, to
assure that facilities and equipment will be available. If any mental or physical health
problem exists, the disaster will most likely exacerbate it, and children with these
problems should be referred back to the previous practitioner for specific assistance.

Families in which a child is born at the time of a disaster or who are in the early stages
of nursing, bonding, and attachment may be another group needing special attention.
New mothers may need additional teaching and support to appreciate and minimize
the impact of the added stressors, as well as practical assistance to access proper food,
water, formula, and supplies.

EFFECTS ON THE PRIMARY CARE PHYSICIAN

The primary care physician can be one of the major sources of information and
support for the child, family, and community before, during, and after a disaster.
Table 2 describes these roles.

TABLE 2. ROLES OF PRIMARY CARE PHYSICIANS IN DISASTERS

Before Teach pediatric emergency techniques to nurses, emergency medical

technicians, and other health professionals

Order pediatric supplies (eg, diapers, baby wipes, intravenous fluids, and
oral electrolyte solutions) for emergency departments, ambulances, and
evacuation shelters

Help families to formulate disaster plans

During Assist medical personnel in triage

Treat those with minor wounds and decide who needs to be hospitalized
After Be available to parents

Teach parents about common behaviors children or adolescents display

Provide referrals for families with children requiring mental health services

Consult with schools

Identify psychiatric or physical signs of stress in children, adolescents, and

families

With all these responsibilities, the primary care physician in the community may also
be coping with personal losses and problems. This role conflict poses a double burden
and should not be ignored.[22,24,25] The need to treat more patients with fewer
supplies and in a less-than- optimal treatment setting may take its toll on caregivers.
Additionally, if the physician's office is damaged or destroyed in the disaster,
rebuilding the structure and practice is a necessity.

Coping with the death of a patient may also be extremely difficult. Speaking with
other physicians about their common experiences may be helpful. Support groups for
physicians, health care providers, and their families are also a venue to help with
coping in the aftermath of the disaster.

From a practical standpoint, with the closing of schools after a disaster, caregivers
may need additional child care. Temporary housing may also be necessary for those
health care professionals who remain and help rebuild the community. Yet the
physician should continually evaluate the balance between personal and professional
demands.

CULTURAL, RELIGIOUS, AND ETHNIC CONSIDERATIONS

There is little research about the unique impact of disasters on specific cultural or
ethnic groups of children, but there are some observations showing differences.[10,26]
Outreach by leaders of different cultural groups in the community is essential in all
phases of a disaster. Information regarding available services should be provided in all
languages appropriate to the community.[14] This information may be distributed
through church and community groups.

Since religion may be a source of comfort to many in the face of loss of life, property,
and sometimes lifestyle, it is important that churches, synagogues, and their clergy
become active in the recovery of the community during and after a disaster. Mutual
referral between the primary care physician and the clergy should be established to aid
families in coping.

REACTIONS OF CHILDREN AND ADOLESCENTS TO A

DISASTER

EARLY VS LATE EFFECTS OF DISASTER

The time course for reactions to a disaster is variable and phases of disaster-related
behaviors are described in Table 3.[16]

TABLE 3. EARLY VS LATE EFFECTS OF A DISASTER [25]

First Stage Second Stage Third Stage

During and
A few days to several
Time immediately Months later
weeks after disaster
after a disaster
Reaction Disbelief, Clinginess, appetite Reconstruction
denial, anxiety, changes, regressive
 symptoms, somatic
complaints,sleep dis-
relief, grief,
turbances, apathy,
altruism
depression, anger, and
hostile, delinquent acts

The first stage occurs during the disaster and immediately after it with the attendant
emotions of fear, "state of shock," acute anxiety, grief after loss, or relief if the family
is intact. There is a great deal of altruism that may even be seen in the willingness of a
schoolchild to help a younger sibling.

The second stage occurs for several weeks after the disaster. Common behaviors
during this time include regression to previous developmental levels and
manifestations of emotional upset, eg, clinginess, change in appetite, enuresis,
constipation, headaches, sleep disturbances, and irritability. Anger over loss, survivor
guilt and suspicion of outsiders, apathy, depression, and withdrawal may occur.
Hostility and violence towards others, pessimism about the future, and posttraumatic
play are not uncommon. Any of these symptoms are within normal expectations,
provided they last only a few weeks, but the child needs a referral to a mental
psychiatric health professional if significant problems persist beyond that. After a
disaster, the child or adolescent may have strong feelings of disappointment or
resentment if a delay occurs in the rebuilding of the home or school. Children may
show signs of posttraumatic stress but few will go on to develop a full- blown
psychiatric disorder.

The reconstructive phase is the last phase and may take several years or decades. This
is the time when the family members are actively rebuilding their lives, and the
physician should monitor and be available to these families. It is important to note that
these phases do not always occur in a sequential fashion and children and families
may regress.

RESPONSES OF CHILDREN AND ADOLESCENTS BY AGE [17]

Generally, a child's reaction is dependent on the following factors:

• proximity to the impact zone

• awareness of the disaster
• physical injury sustained
• amount of disability
• witnessing injury or death of family member or friend
• perceived or actual life threat
• duration of life disruption
• familial and personal property loss
• parental reactions and extent of familial disruption
• child's predisaster state
 • probability of recurrence

The child's response to disaster depends upon his/her own perception of the trauma
which, in turn, is influenced by his/her cognitive and physical development.[29] The
following five primary responses seen in children result from loss, exposure to
trauma, and disruption of routine:

• increased dependency on parents or guardians

• nightmares
• regression in developmental achievements
• specific fears about reminders of the disaster, eg, a toy airplane if the child was
in an airplane crash
• demonstration of the disaster via posttraumatic play and reenactments

These symptoms usually last for a month or so after the disaster. If these behaviors
persist, referral to counseling may be appropriate.

Postdisaster symptoms change with age.[25] Table 4 describes age- specific

symptoms.

DIFFERENCES BY GENDER [24,25]

Responses to a disaster may also vary by gender.

Boys

• take longer to recover

• display more aggressive, antisocial, and violent behaviors

Girls

• are more distressed

• are more verbal about emotions
• ask more questions
• have more frequent thoughts about the disaster

GRIEF AND BEREAVEMENT

After a disaster, the child and adolescent must cope with loss, the greatest of which is
the death of a family member or friend. Destruction of home, school, and possessions
will also cause the child to grieve. Grieving, a search for meaning, and anger are
normal reactions to loss and proceed differently for each child.[8,12]

Table 5 describes the developmental basis for grief reactions in infants, children, and
adolescents. Toddlers, school-age children, and adolescents are able to verbalize
sadness and should be strongly encouraged to do so. The intensity of the grief reaction
will usually be at its peak immediately after the disaster and wane during the next few
weeks. However, the anniversary of the event or the birthday of a deceased loved one
or friend may trigger bereavement and recurrent symptoms, but to a lesser extent. If a
verbal child does not express sadness or denies a sense of loss, or if bereavement is
prolonged, then referral to a mental health professional is advisable.

The presence or absence of emotional support provided by the family and community
for children's grief reactions is significant. The family's reaction may be helpful or
hurtful. Parents also have experienced trauma and loss in disasters, and may initially
display disbelief, denial, and depressive symptoms such as weight loss, insomnia,
poor appetite, alcoholism, and irresponsible behavior.

Bereavement may last from 6 to 12 months. If symptoms persist beyond that, or if

they are excessive with an inability to return to predisaster functioning, referral to a
mental health professional is necessary.

TABLE 5. DEVELOPMENTAL CONSIDERATIONS IN THE

COMPREHENSION OF DEATH IN CHILDREN AND
ADOLESCENTS

Preschool School-Age
Infants Adolescents
Children Children
Magical Logical
Establishing
thinking, thinking,
Object independence,
egocentric, no conception of
Developmental permanence, abstract
concept of time,
considerations establishing thinking,
time differentiation
trust feelings of
of self from
omnipotence
others
Destroys Destroys Destroys Loss of
Effect of
routine, loss of routine, loss routine, loss of lifestyle, loved
disaster
loved ones of loved ones loved ones ones
School
problems,
Risk-taking,
Posttraumatic anxiety,
somatization,
Result of Regression, play, somatic
depression,
disaster detachment withdrawal, complaints,
anger, hostility
apathy anger,
to others
posttraumatic
play
View of No Reversible Understand Full
disaster comprehension loss as a understanding
consequence
of injury and
 illness

SPECIFIC PROBLEMS AND RECOMMENDATIONS

DISRUPTION OF NORMAL PATTERNS

The cardinal effect of a disaster on children and adolescents is the disruption of their
lives, whether through injury, death, or destruction (of home, school, or community).
This leads to a loss of reliability, cohesion, and predictability, which affects children
of all ages. Toddlers usually respond with increased dependency. School-age children,
including preteens, show evidence of the trauma with talk and play about the trauma,
hostility to peers and family members, and avoidance of previously enjoyable
activities. Adolescents also may withdraw, have decreased interests, fatigue,
hypertension, and hostility.[26] Sleep disturbances, such as insomnia, resistance to
bedtime, refusal to sleep alone, early rising, or excessive sleep, are extremely
common. Increased substance abuse, amenorrhea, and teen pregnancy also occur.

It is important for parents and teachers to create and maintain a schedule that is
predictable for the children. Sometimes, especially with sleep disturbances, the
parents need flexibility but also need to establish a routine. Night lights, stuffed
animals, reassurance, and soothing are helpful. Compassion is helpful, but punishment
is not. Discipline can be reinstituted as usual. Consultation with a child psychiatrist
may be considered for children who may benefit from mild tranquilizers for daytime
distress; a hypnotic or sedative at bedtime for continued insomnia also may be
advisable. Parents may need similar consultation.

SOMATIC SYMPTOMS

Somatic problems such as headaches, abdominal pain, and chest pain are commonly
observed in children through adolescence in the weeks following a disaster and are
usually self-limited. If these complaints begin to interfere with the child's life, then the
child and family should be referred for mental health counseling. The primary care
physician can help by reassuring the child and family that these somatic complaints
are not signs of serious physical illness but that they will be addressed and will resolve
with time and proper counseling.

AGGRESSIVE/DEFIANT BEHAVIOR

Hostile behaviors may take the form of hitting, biting, or pinching by toddlers or
preschoolers, or fighting and not getting along with peers among school-age children,
or delinquency and excessive rebellion by adolescents.[26] For the younger child,
simply setting limits on unacceptable behaviors may result in the desired change. With
adolescents, depression and anger about loss of family, routine, or disruption of
community (eg, school or social life) may be expressed in misconduct. Involving them
in rebuilding the community or helping younger children or the elderly may provide
positive outlets for their feelings. Groups, such as the Scouts or school clubs, can be
sites of informal, guided discussions in which preteens and adolescents may feel
comfortable in expressing their fears, feelings of loss, and anxiety. The physician can
help by advising these clubs and by leading discussions.

REPETITIOUS BEHAVIOR

The most common type of repetitious behavior is seen in the play of toddlers and
preschoolers after a disaster.[27] Children will reenact crucial details of a disaster as a
coping mechanism. For example, the end result of a child's "game" about the disaster
may be different from the actual disaster or the child may portray himself or a family
member as a hero.

Other repetitive behaviors are recurrent nightmares, frequent trauma-specific

flashbacks, and distress with reminders of the event. These intrusions can affect
concentration and may be very frightening. Posttraumatic play and reenactments show
that the child is still very much involved with the disaster. The play and/or
reenactments are a necessity for the child although there is no evident joy or
diminution of distress. It is not play in the usual sense of giving pleasure or
immediately relieving distress. The primary care provider should reassure parents that
this play may be therapeutic and can help recovery.[24,27]

REGRESSIVE BEHAVIOR

Separation anxiety symptoms, enuresis, encopresis, thumb-sucking, loss of acquired

speech, increased clinging and whining, and fear of darkness are more commonly seen
in the school-age child and younger child or toddler. These regressive symptoms are
usual and short-lived immediately following a disaster. Parents should be reassured of
this so that punishment and shame are avoided. In the older child and adolescent,
regression may take the form of competing for parental attention with other siblings,
decline in previously responsible behaviors, and extreme dependency. Often a child
may experience transient confusion. If this happens, the child should be reoriented,
and the physician should provide reassurance to parents. If these symptoms last for
more than a few weeks, then counseling for the family and the child is advised.
However, the return of stability and routine to the home, as well as the passage of
time, usually rectify the problem.

ANXIETY

Anxiety occurs in all age groups. One must not minimize or dismiss the expression of
anxiety and should encourage the verbal child and teenager to discuss their fears and
anxieties. Many times the child is the mirror for parental and/or siblings' anxieties.
Thus, family counseling usually is recommended to allow parents and children to
know and try to understand each other's feelings.[23] Children, and especially
adolescents, if accurately informed by the physician, also may feel less anxious.
DEPRESSION

A sense of sadness is common after a disaster. However, if a child or teenager has

persistent symptoms of depression, then psychiatric intervention is warranted. If there
is preexisting depression or other psychopathology in the child or the family, the
disaster may exacerbate it and strongly hinder adequate recovery. Some preteens and
teens may have suicidal thoughts or gestures, especially if a close relative has died. If
a teenager expresses helplessness, hopelessness, suicidal ideation, isolation, or other
depressive symptoms, then psychiatric evaluation is mandatory. Depression is not the
equivalent of sadness, which is usual after a disaster. The physician should alert
parents to the common signs of depression, such as decreased appetite, sleep
disturbances, constant sadness, and irritability.

GUILT

After a natural disaster, there is no one to blame, but children and teenagers may feel
guilty for surviving or having their families and homes intact. They also may feel guilt
for being unable to help, or may blame parents or authority figures for being
unprepared or not taking necessary precautions to protect them.[27] Young children
may experience "magical thinking," resulting in feeling that they are responsible for
the disaster because of something "bad" they did.

In technologic disasters, the same issues apply. However, there may be a person,
company, or government to blame. If litigation is involved, the protracted process may
mitigate against children and their families putting the trauma behind them. This may
result in disillusionment, especially in school-age children and adolescents. Loss of
faith in religion also may occur.

The physician can alleviate guilt by reassuring the child or adolescent that the disaster
was not his or her fault and that all has been done to return life to normal. Also,
instruct the child that assigning blame is counterproductive and that rebuilding lives,
families, and communities is what is important. The physician must comfort and
support the child and family but should not expect an immediate positive response.

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) has been observed in children and adults
following exposure to a traumatic event such as a disaster, but not all children show
all the symptoms of PTSD.[3] Few develop the full disorder. Some may have a
delayed onset while others may have anxiety, depressive, or conduct disorders. Some
children display the symptoms only during the immediate postdisaster period.

The diagnosis of PTSD is made when a child has symptoms with specific additional
criteria in three major categories persisting for more than 1 month:[3]
 1. Intrusive, repeated reexperiencing of the event through play or in trauma-
specific nightmares or flashbacks, or distress with events that resemble or
symbolize the trauma.
2. Routine avoidance of reminders of the event or a general lack of
responsiveness, eg, diminished interests or sense of foreshortened future.
3. Increased general arousal, such as sleep disturbances, irritability, poor
concentration, increased startle reaction, and regression.

GENERAL RECOMMENDATIONS

The most important point to keep in mind for any child in a disaster is that the child
and the family can be helped to recover through working together, with the help of the
practitioner, as they deal with the psychosocial aftermath. These are usually normal
children who have experienced stress from trauma and loss. Secondly, the practitioner
should talk privately to the verbal child. The child's view of what has happened is
often very different from the parents', guardians', or teachers' perceptions.[24]

The practitioner should actively seek out all children and families involved, to let
them know of the available services and to listen to the children, thus legitimizing and
normalizing their fears and grief with support. This also helps parents realize that
what they and their child are experiencing is not abnormal. Some parents are so upset
that they may not be aware of their child's troubles.

LISTENING AND EMPHASIZING STRENGTHS

For the child experiencing the symptoms described above, which are usually self-
limited and cease a few weeks after the disaster, it is important to listen and to
emphasize the child's strengths and abilities to cope with loss and adversity as they did
in the past. It is also helpful to note the child's bravery and courage. The goal is to
decrease the stress for the child and facilitate working through grief by listening and
empathizing with the child and family. Sometimes a child's drawings may be helpful
in expressing fears.[13] Observing a child's play may be helpful in identifying a
child's feelings. Play may be therapeutic for the child.[20] Children are generally
resilient; nevertheless, they need order when their routines have been disrupted.
Parents should be instructed to try to resume as much of their usual routine as soon as
possible; to spend more time with their children in positive activities even of the
simplest kind; and not to interfere in the child's repetitious posttrauma talk and play
(unless dangerous), since the child experiences the intrusion as a rejection.

If symptoms last for more than a month, or if posttraumatic stress disorder, anxiety, or
depression are noted, then referral to a mental health professional should be
considered. Other situations that may require such a referral are children or families
with psychopathology prior to the trauma, those with suicidal ideation, or those with
risky behaviors.
SCREENING TECHNIQUES

The best rapid method for assessing the extent to which a child or adolescent has been
affected by a disaster is a directed history inquiring specifically about the following:

• changes in sleep patterns

• apathetic behavior and lack of motivation
• any regressive behavior (enuresis, encopresis, biting)
• changes in relationships with family members or peers (more clingy and
dependent or withdrawn and isolated)
• grades in school
• fears and worries

In addition to the clinical evaluation, the practitioner can use formal screening scales
in order to assess whether a child is experiencing postdisaster behavior problems.[5]
These scales are usually administered by teachers, social workers, and clinicians. Two
examples are

• The Child Behavior Checklist for 4- to 18-year-olds[1]

• The Pediatric Emotional Distress Scale (PEDS)[21]

A copy of the PEDS is appended for inspection and use. Normative and scoring
information is available from the author.

There are also numerous self-report scales that are being examined in terms of their
ability to screen for posttraumatic stress disorder (PTSD) in children, such as the
following:

 Impact of Events Scale[9]

 Reaction Index[6]
 Children's PTSD Inventory[18]

DETERMINING NEED AND TYPE OF INTERVENTION

The role of the primary care physician is to assess the child and family, and to provide
emotional support and reassurance to them. The physician should make general
recommendations to the family that will ultimately help the child. The main goals are
to keep the family together, to provide support, and to encourage family
communication. Strengthening a child's friendships and peer support also are
important.[11] The physician should emphasize the importance of establishing a
routine and getting life back to normal as much as possible. The practitioner can help
the parents to assign tasks to family members, such as chores for the preteens and
teens, helping children with homework, and setting aside regular times for meals,
play, talking, and bedtime. Several visits may be necessary to assess the coping
abilities and liabilities of the child and family.

KNOW LIMITATIONS

When symptoms are prolonged, then referral for individual and group psychotherapy
is in order. The goal of therapy is to remove or decrease disruptions in the child's
personality development and to get development back on course. Parents and other
family members must be involved and early intervention is important.

OUTSIDE THE OFFICE:

ISSUES FOR COMMUNITY INVOLVEMENT

DISASTER PREPAREDNESS

One important task for the primary care physician is to help the community implement
a disaster preparedness program prior to the disaster.[2] Such programs are even more
critical in localities that are more susceptible to natural disasters, such as California
(earthquakes) or the Gulf and southeastern coasts (hurricanes). Assisting a community
in preparing for a disaster may include providing anticipatory guidance to school
teachers with presentations in the school, and to parents during regular health visits.
These would include the location of local shelters, reviewing first-aid tips, and
discussing symptoms that may occur in a child or adolescent after a disaster. As a
member of the medical community, the practitioner should help determine and
arrange for the availability of necessary pediatric medical equipment in shelters,
ambulances, and hospital emergency rooms.

SCHOOLS

After a disaster, the schools are a natural site for monitoring behavior of children and
adolescents even early in the aftermath when schools are often used as temporary
shelters for families. Collaboration between the physician and school staff is
extremely important. The physician may wish to work with school staff in developing
information about what to expect from their students after a disaster, offer screening
for high-risk problems, and assist in developing a list of referral sources. A set of
postdisaster activities for elementary schoolchildren has been developed to help
children adapt.[11] Additionally, counseling programs for students and/or families can
be set up at school in a mutual partnership with the primary care physician. The
school also can be a base for dissemination of written information to parents and
students. The physician may be helpful in writing or providing guidance to organize
this information. He or she may be asked to be a consultant, eg, to discuss death and
grieving with students and school staff.

MEDIA

Mass media can be effective in informing the public of the status of a disaster, eg,
where and how to get emergency services. The physician may wish to assist those
designing such public service announcements. Additionally, the primary care
physician may be asked to write or talk about the psychosocial sequelae of disasters
for children on radio or television. The physician may also assist in setting up disaster
hotlines, another avenue by which the physician may participate and provide
guidance. The primary care physician also can be an advocate for children and
families to discourage inappropriate or distressing media attention on the disaster
community.[23]

COMMUNITY AGENCIES AND RELIGIOUS ORGANIZATIONS

The primary care physician may be asked to speak to various community

organizations and relief groups, or at churches and synagogues about the health and
psychosocial effects of a disaster on children and adolescents. As a source of
information, the practitioner may wish to work closely with local clergy to share
information to help children and families cope with grief and loss.

REFERENCES

1. Achenbach TM, Edelbrock C. Manual for the Child Behavior Checklist and
Revised Child Behavior Profile. Burlington, VT: Department of Psychiatry,
University of Vermont; 1983
2. American Academy of Pediatrics, Committee on Pediatric Emergency
Medicine. Emergency Medical Services for Children: The Role of the Primary
Care Provider. Elk Grove Village, IL: American Academy of Pediatrics;
1992:96-98
3. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington, DC: American Psychiatric
Association; 1994:424-429
4. Fain RM, Schreir RA. Disaster, stress and the doctor. Med Educ. 1989;23:91-
96
5. Finch AJ, Daugherty TK. Issues in the assessment of posttraumatic stress
disorder in children. In: Saylor CF, ed. Children and Disasters, New York,
NY: Plenum Press; 1993: chap 3
6. Frederick CJ. Children traumatized by catastrophic situations. In: Eth S,
Pynoos RS, eds. Post-Traumatic Stress Disorder in Children. Washington,
DC: American Psychiatric Press; 1985:73-99
7. Gleser GC, Green BL, Winget CN. Prolonged Psychosocial Effects of
Disaster: A Study of Buffalo Creek. New York, NY: Academic Press; 1981
8. Gudas LJ. Concepts of death and loss in childhood and adolescence: a
developmental perspective. In: Saylor CF, ed. Children and Disasters. New
York, NY: Plenum Press; 1993: chap 4
9. Horowitz M, Wilner N, Alvarez W. Impact of events scale: a measure of
subjective stress. Psychosom Med. 1979;41:209-218
10. Joyner CD, Swenson CC. Community level intervention after a disaster. In:
 Saylor CF, ed. Children and Disasters. New York, NY: Plenum Press;
1993:211-232
11. LaGreca AM, Vernberg EM, Silverman WK, Vogel AL, Prinstein MJ.
Helping Children Prepare for and Cope With Disasters: A Manual for
Professionals Working With Elementary School Children. Coral Gables, FL:
University of Miami, Department of Psychology; 1994
12. Koocher GP, Berman SJ. Children's perceptions of death. In: Levine MD,
Carey WB, Crocker AC, Gross RT, eds. Developmental-Behavioral
Pediatrics. Philadelphia, PA: WB Saunders Co; 1983:491-500
13. Lystad MH, ed. National Institute of Mental Health, Center for Mental Health
Studies of Emergencies. Innovations in Mental Health Services to Disaster
Victims. Washington, DC: US Department of Health and Human Services;
1990; Publication No. (ADM) 90-1390
14. National Institute of Mental Health. Field Manual for Human Service Workers
in Major Disasters. Washington, DC: US Department of Health and Human
Services; 1990; Publication No. (ADM) 90-537
15. National Institute of Mental Health. Manual for Child Health Workers in
Major Disasters. Washington, DC; US Department of Health and Human
Services; 1986; Publication No. (ADM) 86-1070
16. National Institute for Mental Health. Human Problems in Major Disasters: A
Training Curriculum for Emergency Medical Personnel. Washington, DC: US
Department of Health and Human Services; 1987; Publication No. (ADM) 87-
1505
17. Pynoos RS, Nader K. Mental health disturbances in children exposed to
disaster: preventive intervention strategies. In: Goldston S, Yaker J, Heinicke
C, Pynoos RS, eds. Preventing Mental Health Disturbances in Childhood.
Washington, DC: American Psychiatric Press; 1990:211-234
18. Saigh PA. The development and validation of the children's post- traumatic
stress disorder inventory. Int J Special Educ. 1989;4:75-84
19. Saylor CF. Introduction: Children and Disasters: Clinical and Research Issues.
In: Saylor CF, ed. Children and Disasters. New York. NY: Plenum Press;
1993:1-10
20. Saylor CF, Swenson C, Powell P. Hugo blows down the broccoli: pre-
schoolers post-disaster and adjustment. Child Psychiatry Hum Dev.
1992;22(3):139-149
21. Saylor CF, Swenson C, Stokes S. The Pediatric Emotional Distress Scale
(PEDS), a brief screening measure for child trauma victims. Presented at the
Annual Meeting of the American Psychological Association; August 1994;
Los Angeles, CA
22. Stuart GW, Huggins E. Caring for the caretakers in times of disaster. J Child
Adolesc Psychiatry Mental Health Nurs. 1990;3(4):144-147
23. Sugar M. Children and the multiple trauma in a disaster. In: Anthony EJ, ed.
Child and His Family: Perilous Development: Child Raising and Identity
Formation Under Stress. New York, NY: John Wiley and Sons, Inc;
1988:429-442
24. Sugar M. Children in a disaster: an overview. Child Psychiatry Hum Dev.
 1989;19(3):163-179
25. Sugar M. Disasters. In: Levine MD, Carey WB, Crocker AC, eds.
Developmental-Behavioral Pediatrics. Philadelphia, PA: WB Saunders Co;
1992:178-181
26. Sugar M. Adolescents and their reactions to disaster. Presented at the Annual
Meeting of the American Society for Adolescent Psychiatry; May 1992; San
Francisco, CA
27. Sugar M. A preschooler in a disaster. Am J Psychother. 1988;42:619-629
28. Swenson CC, Klingman A. Children and war. In: Saylor CF, ed. Children and
Disasters. New York, NY: Plenum Press; 1993:137-164
29. Vogel J, Vernberg EM. Children's psychological responses to disaster. Journal
of Clinical Child Psychology. 1993;22:470-484
30. Yule W. Technology-related disasters. In: Saylor CF, ed. Children and
Disasters. New York, NY: Plenum Press; 1993: chap 6

Appendix A

POTENTIAL RESOURCES IN A DISASTER ENVIRONMENT

STATE AND LOCAL

Mental Health

All areas should have mental health services for children and their families. At times
of widespread disaster, local or state-wide mental health agencies may be the
recipients of rapid-review federal "Outreach" grants to provide trauma-related
intervention. Contact local mental health center or, if not satisfied, state agency
responsible for mental health services for children.

Schools and Out-of-Home Child Care Centers

School guidance programs frequently offer group support activities for children and
parents when a large number are affected. Parents should be encouraged to take
advantage of free groups and information sessions when they are ready and able.

American Red Cross

The American Red Cross has chapters in most larger cities, and a state chapter in each
capital city. They should be able to help families with immediate basic needs (food,
clothing, shelter) as well as supportive services and longer term interventions. Call
the local chapter for assistance, or if not satisfied, the state chapter in your
capital city.

Professional Organizations

Many disciplines have assembled resources and networks at national and state levels.
This may include information and/or professionals qualified to serve as volunteers or
consultants. For example, the American Psychological Association and the American
Red Cross have established a formal agreement and network so that each state will
have psychologists trained and available for emergency crisis intervention and/or
longer term triage and referral. Contact your state association offices (usually in the
capital city) for the disaster coordinator, or call national contacts listed below.

Churches

Churches are often the most productive and rapid responders for immediate basic
needs. Most organized denominations have some kind of disaster relief program now.
Contact the district office of the major denominations in your area.

Universities and Medical Universities

In many of the large-scale disasters of the last few years, academic practitioners with
general training in stress, coping, counseling, and posttraumatic stress disorder have
stepped forth to be of assistance. Some caution is advised so that your patients are
treated appropriately and not enlisted into a hastily designed research study or given
treatments designed for traditional psychiatric disorders. Be sure that those to whom
you refer patients have specific training in child and family issues and, ideally, in the
specific effects of trauma. Contact your local university's departments of
psychiatry, psychology, or pediatrics (many major pediatrics departments have
their own psychologists, psychiatrists, and/or social workers).

Media

TV, radio, and newspapers should provide listings of available resources and supports
in major disasters.

NATIONAL LEVEL

Federal Emergency Management Agency (FEMA)

This federal agency is charged with intervening to provide logistical and financial
assistance to individuals, businesses (via the Small Business Administration), and
communities after an officially declared disaster (800/621-3362).

Emergency Services and Disaster Relief Branch Center for Mental Health
Services

This center provides publications and videotapes regarding human responses to

disasters. During disasters, it provides funding through an interagency agreement with
FEMA for crisis counseling and training to disaster survivors. It can provide
consultation regarding disaster preparedness and natural and human-caused
emergencies and disasters (301/443-4735).

Office of Public Affairs, Centers for Disease Control and Prevention

This office provides epidemiologic intelligence, health surveys, and broad-based

consultation in times of disasters. Contact through state health officer or (404/639-
3286).

Professional Organizations

Many professional organizations have gathered research, generated handouts, and

developed networks of qualified consultants. Potentially helpful organizations include
but are not limited to:

• American Psychological Association

202/336-5898
• American Academy of Child and Adolescent Psychiatry
202/966-7300
• National Academy of School Psychologists
301/608-0500
• American Nurses Association
202/554-4444
• )American Academy of Pediatrics
708/228-5005

With all potential resources, it is important to note that the agencies and relief groups
themselves, at a local level, may be as disrupted as the community at large (eg, no
electric power, employees involved in catastrophes at home, or medical personnel
engaged in emergency activities at regional medical centers).

Appendix B

PEDIATRIC EMOTIONAL DISTRESS SCALE (PEDS)*

If you have a child between the ages of 2 and 10: Please circle one number for each
item to describe how often your child has shown each behavior IN THE LAST
MONTH.

Gender of child to be rated (M/F)____

Child's birth date:(M/D/Y)___________

Almost Very
Sometimes Often
Never Often
1. Acts whiny 1 2 3 4
2. Wants things right away 1 2 3 4
3. Refuses to sleep alone 1 2 3 4
4. Has trouble going to bed/falling asleep 1 2 3 4
5. Has bad dreams 1 2 3 4
6. Seems fearful without good reason 1 2 3 4
7. Seems worried 1 2 3 4
8. Cries without good reason 1 2 3 4
9. Seems sad and withdrawn 1 2 3 4
10. Clings to adults/doesn't want to be alone 1 2 3 4
11. Seems "hyperactive" 1 2 3 4
12. Has temper tantrums 1 2 3 4
13. Gets frustrated too easily 1 2 3 4
14. Complains about aches and pains 1 2 3 4
15. Acts younger than used to for age (ie,
1 2 3 4
bedwetting, baby talk, thumbsucking)
16. Seems to be easily startled 1 2 3 4
17. Acts aggressively 1 2 3 4
18. Creates games, stories, or pictures
1 2 3 4
about____________________
19. Brings up____________________in
1 2 3 4
conversation.
20. Avoids talking
about____________________even when 1 2 3 4
asked.
21. Seems fearful of things that are
1 2 3 4
reminders of____________________

If your child has had a major trauma or stress in the last year, please describe it on the
line provided (eg, loved one in the war, illness, death or loss, accident, natural
disaster). Then rate their behavior with regard to the trauma/stress. (Describe
trauma/stress.)
_________________________________________________

Saylor, Swenson, and Stokes, 1994

*For additional information contact Dr. Saylor at (803) 953-5320

SMA95-3022
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